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N.- <br /> t <br /> APPLICATION FOR SANITATION PERMIT Permit No. _.::��____(_.•�..__..___ <br /> (Complete in Duplicate) <br /> __Date.Issued <br /> Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance Up. 549. <br /> JOB ADDRESS AND LOCATION______--.- `-._ 3f_____01fie. J <br /> - --------------------------------------------------------- <br /> Owner's Name - ` - ------- Phone-------- <br /> Address_.__...__... t <br /> ------------•---------------------------- -- -• --•--------------• --- ---- <br /> Contractor's Name-------------------- <br /> ---------- ' <br /> ---------------------------------------------- ------•--------•------- •---------•----•--- Phone = <br /> Installation will serve: Residence E40 Apartment House Commercial u} <br /> rt❑ ❑ Trailer Court ❑ Motel ❑ Other <br /> Number of livingunits: __/____ Number of bedrooms __ __ umber of bathe ______ _ Lot size ._______-_. <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table .---____ ft. <br /> Character of soil to a depth of 3 feef:Sand C] Gravel ❑ Sandy Loam ❑lCla�y Loam ❑ Clay ❑ Adobe C[�Hardpan E]Previous Application Made: Yes ❑-<O ❑ New Construction: Yes E}- OEJ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if pu lic sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearesf we _ _�____ .__Distance from founda ion___ �__._'----Material______ <br /> No. of compartments____________________ _____Size___3_X__ __. .___Liquid depth------- Capacity___._ <br /> � f l <br /> Disposal Field: Distance from neare well-_!I/_ ____Distance from foundation___-_ _. __ .:-__-.Distance to nearest lot line------------__ <br /> P44- Number of lines------ ______Length of each line_ __ <br /> g _. _ - -- Width of trench -� --- ,- --- -- <br /> Type of filter material-- _______________Depth of filter material____ <br /> __--_-Total length----__�._( _ _ J <br /> --------•---•-- <br /> Seepage Pit: Distance to nearest well____________________Distance from foundation---------------------Distance to nearest lot line______._____-__- <br /> El' Number ofits_______________ <br /> p - ---Lining material-----------------------Size: Diameter------------------ ----Depth------------•---------------- --- <br /> a <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.___-____________.___---_____.____. <br /> 171 <br /> - --------Depth--------------- --Liquid Capacity-------------------------A--gals. <br /> Size: Diameter- ----------------------- ---••----------- ------- -- <br /> Privy: Distance from nearest well_______________________________________________,._Distance from nearest building--- ------------- <br /> ------------------------ <br /> ❑ Distance..to nearest lof line----------------- <br /> ---------- --•---------------------------------------- <br /> emo e ing and/or repairing(describe) ---------- <br /> , <br /> --------------------------------------------------...-------------•------------------------------------------•---------------------- - <br /> FE <br /> ---------------------------------------------------------------•-•----------------------------------------------------------------------- ---------- - ro <br /> --------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> I hereby cerfify-that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and r es and regulations of the San Joaquin Local Health District. <br /> 1 ' <br /> (Signed)... ,�( -1t-------------------- <br /> - -------------•------------ ----------------------------- -- ------{Owner and/or Contractor) <br /> BY: ; ---------------------------------------------------- -�----------------------- --------------(Title)-------- <br /> (Plot plan, showing size`of'lot, location of system in relation to wells, buildings, etc., can be placed'on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------y--- ------------ ---- ' <br /> ------------------------------------- ---- - DATE-------- <br /> REVIEWED BY------------------- <br /> . <br /> -------------------------------------------------------I------------------------------------------------- DATE <br /> - ------�•-------------•---=--------- <br /> BUILDING PERMIT ISSUED_..---•----------------------•----------------------------------------------------------------------- DATE----------------------- - ------------------------------ <br /> -- --- <br /> Alterations and/or recommendations-------------------------------------------------------------------------- <br /> --------- ----------------------------------------------••------•---•--------------------- <br /> e , <br /> _'_--^---'-------------'-----•---------------------------------------------------------------------- ----•---------` <br /> _ -----------------_---------•-----------------------------------------------• <br /> ------------ <br /> -----------------------------------•----------------------------.----------------------------------------------------- ------ <br /> y <br /> ,� J� J� � <br /> FINAL INSPECTION BY-------- -------------- ------- j�- f�� Date------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH,DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />